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Sudden
Roof Collapse of a Burning Auto Parts Store Claims the Lives of
Two Fire FightersVirginia

Death in the Line of Duty...A summary of a NIOSH fire fighter fatality investigation

F96-17 Date Released: May 20, 1996

INTRODUCTION

On March 18, 1996, two male fire fighters (38-and 32-years-old)
died while fighting a fire in an auto parts store. On April 8,
1996, the International Association of Fire Fighters (IAFF)
notified the Division of Safety Research (DSR) of the fatalities,
and requested technical assistance in investigating the
circumstances of the deaths of these two fire fighters. On April
15, 1996, the Chief of Trauma Investigations Section traveled to
Virginia to conduct an investigation of this incident. Meetings
were conducted with Virginia OSHA personnel, the fire department
battalion/fire marshall, fire department investigators, fire
fighters involved in the incident, and the IAFF union
representative. Copies of photographs of the incident site and
the transcription of dispatch tapes were obtained, and a site
visit was conducted.

The fire department involved in the incident serves a population
of 183,000 in a geographic area of 350 square miles. The fire
department is comprised of approximately 320 workers, of whom 258
are fire fighters. The fire department provides all new fire
fighters with the basic 13-week training at the fire academy, and
requires 2 hours additional on-the-job training per shift. The
daily training scheduled is developed by the training officer and
is sent to all stations. The required training is designed to
cover fire department operation, e.g., ladder training, aerial
operations, hose training, breathing apparatus, etc. The written
standard operating procedures manual was reviewed and appears to
be complete.

The site of the incident (auto parts store - measuring 50 feet by
120 feet) was located in a strip mall which was built in 1984.
Most of the stores in the mall were built with masonry walls and
steel trusses. However, the auto parts store had wooden 2-by
6-inch trusses that spanned the 50-foot width. The store had
three heating-ventilation-air-conditioning (HVAC)units mounted on
the roof, with an estimated total weight of 3000 pounds (Figure).

Although several fire companies were involved in this incident as
shown in the figure, only those directly involved up to the time
of the fatal incident are cited in this report.

INVESTIGATION

On March 18, 1996, at 1129 hours, a call came into the
fire/police dispatcher from an auto parts store in a strip
shopping mall, reporting sparking and popping from an inside
"fuse box". Engine 3, Engine 1, Ladder 2, and Battalion
2 were ordered to respond. Engine 3 was the first on the scene
(1135 hours) and assumed command. When Engine 3 pulled up in
front of the auto parts store, no smoke or fire was visible.

It was not known to the fire fighters arriving on the scene, that
the reported sparking in the fuse box was caused when the boom of
a power company truck had accidentally broken the neutral line on
the 208/120 volt three-phase service drop to the auto parts
store. An investigation conducted by the power company revealed
the panel box in the auto parts store was improperly grounded;
therefore, when the neutral was broken, the power surge did not
go to ground at the panel box; it traveled throughout the
electrical circuitry causing electrical fires at each circuit
connection. For example, the electric hot water tank caught fire
and the wiring in electrical junction boxes of the HVAC units on
the roof of the store were fused together from the extreme heat
created by the short-circuit.

The Acting Lieutenant and a fire fighter specialist entered the
front door of the store to investigate, while the driver of
Engine 3 went to the side door. Although the lights were off in
the store, the large plate glass windows in the front provided
enough light in the store to see there was not any smoke inside
the store, and that "it looked clear."

At 1137 hours, the driver of Engine 3 heard the Acting Lieutenant
calling on the radio (Portable 3), so he went back to the Engine,
and received instructions from Portable 3 to reposition the
Engine to the rear of the building. While driving the Engine to
the rear of the building, the driver noticed a little smoke
coming from the edge of the roof, and also heard the transmission
from Portable 3 to Battalion 2 (1138 hours), that Engine 3 and
Ladder 2 could handle the situation. When the driver of Engine 3
arrived at the rear of the auto parts store, the Acting
Lieutenant and the fire fighter specialist were coming out the
rear door. Battalion 2 now ordered Engine 1 back into service.
Engine 3 driver asked if they had noticed the smoke, which was
now more intense and noticeable, coming from the roof, and they
stated, yes. At this point, the fire fighters from Engine 3
pulled off the first 1 3/4-inch hose. The Acting Lieutenant took
the charged line and went back inside the store, returning
shortly to pull a second line. While the fire fighter specialist
was donning his self-contained breathing apparatus (SCBA), the
Acting Lieutenant was using the second line to knock down the
fire that was coming through the edge of the roof. When the fire
fighter specialist donned his SCBA, he and the Acting Lieutenant
entered the back door with the second charged line.

At 1140 hours, Battalion 2 was now on the fire scene and received
a transmission from Engine 3 (Portable 3) to strike a second
alarm. Battalion 2 also requested police assistance from dispatch
to help evacuate the adjoining buildings.

At 1141 hours, dispatch ordered Engine 14 and Engine 2 to respond
to the second alarm.

At 1142 hours, Engine 3 (Portable 3--inside the auto part store)
requested pike poles and assistance in removing the ceiling.
Meanwhile, Engine 3 at the rear of the store was calling for an
Engine to lay a supply line, as he would be out of water shortly.

At 1145 hours two fire fighters from Ladder 2 positioned their
unit facing the auto parts store. They walked up to the front
door and observed a brisk wind (approximately 30 miles per hour)
blowing through the thick black smoke in the store. They could
not see any fire, but the blowing wind, and the heavy smoke made
it apparent that there was a heavy fire somewhere, so they
decided not to enter the building.

At 1149 hours, Portable 3, inside the auto parts store, radioed
that they were in trouble and could not get out. However, due to
the heavy radio traffic, Battalion 2 (positioned in front of the
store) did not understand the transmission. Battalion 1, en route
to the fire scene had picked up the radio transmission and
radioed Battalion 2 that the transmission sounded like someone
was trapped inside the building.

At 1150 hours, without warning, the fire accelerated rapidly, and
the entire roof collapsed into the auto parts store.

The building was now totally engulfed in fire and conditions were
changing rapidly: a fire fighter from Engine 1 noticed that the
hose line leading into the rear door of the building had burned
through, allowing water to flow freely; numerous explosions were
heard inside the store (overheating pressurized cans); and Engine
3 had to be moved for fear of losing the Engine due to the
extreme heat as the fire was being whipped over the Engine.

At 1208 hours, Battalion 2 stated he may have two fire fighters
down inside the burning building. Fire suppression operations
continued, using multiple streams to contain and extinguish the
fire. The two fire fighters (Acting Lieutenant and fire fighter
specialist) inside the building were unable to escape as the roof
collapsed and died in the fire.

CAUSE OF DEATH

Preliminary cause of death was listed by the medical examiner as
body burns and smoke inhalation.

RECOMMENDATIONS/DISCUSSION

Recommendation #1: Fire departments should ensure
that fire command always maintains close accountability for all
personnel at the fire scene. [1-4]

Discussion: Accountability for all fire fighters at a fire scene
is paramount, and one of the fire commands' most important
duties. Although the Acting Lieutenant from Engine 3 had assumed
command upon arrival at the incident site, informal transfer of
command was assumed by Battalion 2 upon arrival. However,
Battalion 2 was positioned in front of the auto part store and
was not aware of the two fire fighters in the store. The driver
of Engine 3 was not in a position at the rear of the store to
determine the location of the Acting Lieutenant and fire fighter
specialist who had entered the rear door. His line of sight was
blocked by a trailer parked at the rear of the store. He assumed
they had gone out the front of the store. One method of
accountability is a buddy or team system, whereby, if any part of
a team is not accounted for, fire command is notified
immediately, signaling that a potential life-threatening problem
may exist.

Recommendation #2: Fire departments should ensure
at least four fire fighters be on the scene before initiating
interior fire fighting operations at a working structural fire.
[2,5]

Discussion: When Engine 3 arrived at the auto parts store, no
fire was showing, and very little smoke was visible. However,
within a few minutes, fire and smoke were visible from the rear
of the store. Unaware of the involvement between the suspended
ceiling and the roof, the fire fighters proceeded into the auto
parts store with a charged line to knock down any visible fire
from the inside. The driver of Engine 3 was busy pulling line and
running the pump, and he was not in line of sight or
communication with the two fire fighters inside the building. The
National Fire Protection Association (NFPA) recommends that four
persons (two in and two out) each with protective clothing and
respiratory protection is the minimum number essential for the
safety of those performing work inside a structure. The team
members should be in communication with each other through
visual, audible, or electronic means to coordinate all
activities, and determine if emergency rescue is needed.

Recommendation #3: Fire departments should ensure
that standard operating procedures and equipment are adequate and
sufficient to support the volume of radio traffic at
multiple-responder fire scenes. [3]

Discussion: The fire ground communications at the fire scene
became ineffective at times because of all the radio traffic,
dispatch messages, and noise at the fire ground. All
communication at the fire scene was on channel 1, not channel 2,
the tactical channel. Therefore, all communications between
dispatch and all those on channel 1 were competing for air time.
Battalion 2, stationed in front of the auto parts store, was not
able to receive and understand the emergency transmission from
Engine 3 fire fighters inside the building that they were in
trouble. The standard operating procedures and communications
equipment should be of sufficient quality to support the volume
of communications encountered at this fire scene.

Recommendation #4: Fire departments should ensure
that pre-fire planning and inspections cover all structural
building materials/components.

Discussion: The strip mall was built prior to 1984 of masonry
walls and steel supported roof trusses. In 1984 the auto parts
store was built at the East end of the shopping mall of masonry
walls and wood roof trusses. The auto parts store had wooden
trusses that spanned a 50-foot width, plus had three HVAC units
mounted on the top, with an estimated weight of 3000 pounds.
Wooden roof trusses used in building construction should have a
minimum fire resistance rating (the length of time the member can
be subjected to a standard fire test without failing) of 1 hour.
[6] Each structure in a multi-structure unit should be pre-fire
inspected to determine interior design and the type of materials
used in construction.

Recommendation #5: Municipalities should ensure
that all electrical circuits are installed in accordance with the
National Electrical Code, and fire departments should include
electrical inspection on pre-fire planning and inspection. [7]

Discussion: An investigation in to the circumstances of this
incident revealed there was no driven ground at the electrical
distribution panel, and the potable water system that was being
used for a ground consisted of a combination of copper piping and
polymer piping. The electrical system was not properly grounded,
and a short circuit was initiated by the accidental contact
between the electric company truck boom and the service drop
which broke the neutral conductor, producing hot connec- tions
throughout the electrical system in the store.

The National Institute for Occupational Safety and
Health (NIOSH), Division of Safety Research (DSR),
performs Fatality Assessment and Control Evaluation
(FACE) investigations when a participating State reports
an occupational fatality and requests technical
assistance. The goal of these evaluations is to prevent
fatal work injuries in the future by studying the working
environment, the worker, the task the worker was
performing, the tools the worker was using, the energy
exchange resulting in fatal injury, and the role of
management in controlling how these factors interact.

States participating in this study: North Carolina, Ohio,
Pennsylvania, South Carolina, Tennessee, Virginia, and
West Virginia.